Iron and Anaemia in Older Adults

What anaemia is

Anaemia is defined by a low haemoglobin level. The World Health Organization uses cut-offs of about 13 g/dL for men and 12 g/dL for non-pregnant women (laboratories and guidelines vary slightly, and some older-adult studies use slightly different thresholds). Mild anaemia may cause no symptoms; moderate and severe anaemia can strain the heart.

Symptoms

• Tiredness, weakness, reduced stamina.
• Breathlessness with effort, or at rest in severe cases.
• Pale skin, pale inner eyelids and nails.
• Fast or pounding heartbeat, chest pain on exertion (angina) in people with heart disease.
• Dizziness, light-headedness, headache, fainting.
• Cold hands and feet.
• Poor concentration, irritability, low mood, and sometimes confusion in older adults.
• Brittle nails, hair loss, sore tongue, mouth cracks, restless legs, or a craving to chew ice or non-food items (pica) in iron deficiency.
• Falls.
• Worsening of heart failure or angina.

Symptoms are non-specific, so a blood test is needed. See fatigue and anaemia in older adults.

Causes in older adults

• Iron deficiency: the commonest type worldwide. Causes include chronic blood loss (from stomach or duodenal ulcers, gastritis from painkillers such as aspirin and other NSAIDs, piles, bowel polyps or cancer, oesophageal problems, worm infestation, heavy use of blood thinners), poor diet, poor absorption (coeliac disease, stomach surgery, long-term acid reducers, atrophic gastritis) and, less often in older adults, other causes of loss. In an older man or a post-menopausal woman, iron deficiency anaemia is considered a sign of possible gut bleeding until proven otherwise, and the doctor usually arranges tests such as endoscopy or colonoscopy.
• Vitamin B12 and folate deficiency: common, especially in vegetarians and in people on metformin or acid reducers; see vitamin B12 in older vegetarians.
• Anaemia of chronic disease or inflammation: from infections (such as tuberculosis), arthritis, cancers, heart failure and other long-term illnesses.
• Chronic kidney disease: the kidneys make erythropoietin, which stimulates red cell production; see chronic kidney disease: a home care guide.
• Bone marrow disorders and blood cancers, and treatments such as chemotherapy.
• Haemolysis (red cell destruction), thalassaemia trait and other inherited conditions.
• Thyroid disease; see thyroid problems in older adults.
• Medicines that cause bleeding or bone marrow suppression.
• Mixed causes, which are common in older adults.

Why diagnosis comes first

Taking iron without a diagnosis has problems:

• It may not help, if the anaemia is due to B12 deficiency, kidney disease or chronic illness.
• It may mask a serious problem, delaying detection of bleeding or cancer.
• It may harm: iron overload in people who do not need it (including those with haemochromatosis or thalassaemia), constipation, nausea and black stools that hide bleeding.
• It treats a symptom, not the cause.

Do not buy iron tonics or tablets on your own for a parent with tiredness or paleness. See a doctor.

Tests the doctor may order

• Complete blood count: haemoglobin, red cell size (MCV), red cell indices, white cells and platelets.
• Peripheral blood smear.
• Iron studies: ferritin (stores), serum iron, transferrin saturation and TIBC. Ferritin below about 30 ng/mL suggests iron deficiency (higher cut-offs apply in inflammation).
• Vitamin B12 and folate levels.
• Kidney function, thyroid, liver tests, inflammatory markers.
• Reticulocyte count.
• Stool tests for occult blood, stool examination for parasites.
• Endoscopy and colonoscopy or imaging to look for bleeding sources, particularly in iron deficiency.
• Coeliac blood test if suspected.
• Bone marrow examination in selected cases.

Treatment: iron deficiency

### Treat the cause first

The doctor treats bleeding sources (ulcers, piles, polyps, tumours), reviews medicines (aspirin, NSAIDs, anticoagulants), treats infections and malabsorption, and manages kidney disease.

### Iron supplements

• Oral iron: the usual first treatment. Common forms are ferrous sulphate, ferrous fumarate, ferrous gluconate and newer salts, with differing elemental iron content; tablets typically contain about 30 to 100 mg of elemental iron. The doctor chooses the dose, often one tablet once a day, or, increasingly, alternate-day dosing, which can improve absorption and reduce side effects. Do not exceed the prescribed dose. Overdose is dangerous.
• Timing: best absorbed on an empty stomach, with water or a source of vitamin C (such as a glass of orange or lemon juice), but if it upsets the stomach, take with a small amount of food. Avoid taking with tea, coffee, milk, calcium supplements, antacids or high-fibre foods, which reduce absorption.
• Duration: usually three to six months or until haemoglobin normalises, then continued for a while to refill stores (often a few months); haemoglobin typically rises over several weeks. The doctor repeats blood tests to check response.
• Intravenous iron or injections: used for severe deficiency, intolerance or poor absorption, kidney disease and some other conditions, under medical supervision in a hospital.
• Blood transfusion: for severe anaemia with symptoms, heart problems or active bleeding.
• Other treatments: B12, folate, erythropoietin and treatment of underlying disease as appropriate.

### Side effects of oral iron

• Constipation or diarrhoea, nausea, stomach pain, heartburn; see constipation in older adults: fibre, fluids and movement.
• Dark green or black stools: common and harmless with iron, but black, tarry, sticky, foul-smelling stools can also signal bleeding. If unsure, tell the doctor.
• Metallic taste, tooth staining (liquid forms).
• Overdose and toxicity: vomiting, abdominal pain, drowsiness, fast heartbeat; keep tablets out of children's reach; seek urgent help; call 112 for suspected overdose.

### Interactions

• Levothyroxine, some antibiotics (tetracyclines, quinolones), bisphosphonates, levodopa and others: iron reduces absorption; separate by several hours as the pharmacist advises.
• Calcium, magnesium, zinc supplements and antacids: reduce iron absorption; separate.
• Acid reducers reduce iron absorption.
• Tea, coffee and phytate-rich foods reduce absorption.
• See supplements and medicine interactions: a safety guide and calcium and vitamin D after 60: doses, food and sun.

Iron-rich Indian foods and absorption

Types of dietary iron: haem iron (from meat, poultry and fish) is absorbed well; non-haem iron (from plants, eggs, dairy) is absorbed less, but its absorption improves with vitamin C and falls with tea, coffee, calcium and phytates.

Sources: - Plant foods: green leafy vegetables (amaranth, methi, palak, drumstick leaves, mustard greens, colocasia leaves), dals and pulses (moong, masoor, chana, rajma, lobia), soya, sesame seeds (til), pumpkin seeds, garden cress seeds (halim), jaggery (gur) in small amounts, dates, raisins, figs, dried apricots, ragi, bajra, whole grains, poha (beaten rice), beetroot, pomegranate, nuts. - Animal foods: liver, red meat, chicken, fish, eggs. - Cooking in an iron kadhai or tawa adds a little iron to food, especially acidic dishes; it is a traditional and helpful aid.

Tips to improve absorption - Add vitamin C: lemon juice on dals and greens, amla, guava, orange, tomato, capsicum, raw mango in chutney, with iron-rich meals. - Separate tea and coffee from meals by one to two hours. - Soak, sprout, ferment and cook pulses and grains, which reduces phytates. - Do not take calcium supplements or large amounts of dairy with the main iron-rich meal. - Combine foods: dal with lemon, palak with tomato, sprouts chaat with lemon.

Food alone seldom corrects significant iron deficiency in an older adult, but it helps prevent recurrence and supports treatment. See high-protein Indian meals for seniors, balanced diet chart plan for elderly people and benefits of spinach, keeping in mind that spinach's iron is poorly absorbed because of oxalates and that it should be combined with vitamin C.

Heart, kidney and other conditions

• Heart disease and heart failure: anaemia worsens breathlessness and angina; treatment may include intravenous iron; the cardiologist decides.
• Kidney disease: anaemia is common and treated with iron, erythropoietin and other measures; do not self-treat; see eating with chronic kidney disease: a family guide.
• Diabetes: coexisting kidney problems and metformin-related B12 deficiency.
• Cancer and chronic infection: specialist management.
• Blood thinners: anaemia may signal bleeding; tell the doctor; see atrial fibrillation and blood thinners: a family guide.

Monitoring

• Repeat blood tests as the doctor advises, often after one to two months of treatment and again later.
• Track symptoms, energy and walking ability.
• Report side effects rather than stopping on your own.
• Follow up on investigations such as endoscopy; do not skip them.

Red flags: seek help promptly

• Black, tarry or bloody stools, or blood on toilet paper.
• Vomiting blood or coffee-ground vomit.
• Chest pain, severe breathlessness, fainting, a very fast heartbeat: call 112.
• Worsening tiredness or paleness despite treatment.
• Unexplained weight loss, change in bowel habit, abdominal pain.
• Heavy vaginal bleeding after menopause.
• Confusion or new falls.
• Yellow skin or eyes, dark urine (possible haemolysis or liver problem).

When to ask a professional

Ask the doctor to find the cause of anaemia, to order tests and to prescribe the right treatment. Ask a dietician for an iron-rich, culturally suited meal plan. Ask a pharmacist about timing and interactions of iron tablets. Do not start iron on your own. Seek urgent help for bleeding, chest pain, severe breathlessness or fainting.